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Hallux Valgus Workup

  • Author: Crista J Frank, DPM; Chief Editor: Anthony E Johnson, MD  more...
 
Updated: Jul 18, 2016
 

Laboratory Studies

Generally, laboratory studies are not required for a routine assessment. However, if systemic or metabolic disease is suspected, the following studies can be of value in determining etiology or disease activity:

  • Uric acid [4]
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • Antinuclear antibody (ANA)
  • Rheumatoid factor (RF) [5]
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Imaging Studies

Radiography continues to be the standard means with which to assess joint pathology and measure angular deformity. Other imaging studies usually do not help in determining the degree of deformity or in evaluating the condition of the joint. However, one possible adjunct study is radionuclide imaging[6] to rule out osteomyelitis if ulceration is present and if the radiographic findings are inconclusive.

Radiographic views

Weightbearing anteroposterior (AP), lateral oblique (LO), lateral (LAT) projections, and sesamoid axial view should be obtained in the angle and base of gait (see the images below). Nonweightbearing radiographs may reveal the osseous relationships differently, causing an improper selection of surgical procedure. Weightbearing radiographs demonstrate the structural status of the foot.

Anteroposterior and lateral radiographs, weightbea Anteroposterior and lateral radiographs, weightbearing views.
Medial bony enlargement is more prominent on this Medial bony enlargement is more prominent on this lateral oblique projection than on other views.

The AP projection is used to determine the intermetatarsal angle, metatarsus adductus angle, hallux abductus angle, proximal articular set angle, and hallux abductus interphalangeus, as well as the first metatarsal length, sesamoid position, first metatarsophalangeal (MTP) joint condition, bone stock, first metatarsal base, hallux rotation, and medial metatarsal head enlargement (see the images below).

Template showing angular measurements. Template showing angular measurements.
Another template showing increased angular relatio Another template showing increased angular relationships.

The LAT projection is used to determine first metatarsal sagittal plane position and dorsal exostosis and/or osteophytes.

The LO projection is useful in evaluating bone stock and presence of dorsomedial exostosis. Because the bunion is located on the dorsomedial aspect of the metatarsal head, the prominence may be appreciated fully only in an oblique view.

In the sesamoid axial view, the sesamoids are observed for any lateral subluxation out of their respective grooves. As well, the crista is evaluated for erosion created by this subluxation. The joint sesamoid-metatarsal joint space is also examined for degenerative changes.[7]

Radiographic angular relations

Various angles, structures, and positions are assessed as listed below.

The normal intermetatarsal angle is 8-12° in a rectus foot and 8-10° in an adductus foot type. This angle is the relation between the longitudinal axis of the first and second metatarsals. If the angle is increased, the condition is termed metatarsus primus adductus.[8]

The normal metatarsus adductus angle is less than 15°; more than 15° is considered adductus. This angle is the relation between the longitudinal axis of the lesser tarsus and the second metatarsal. This angle indicates whether the forefoot is in a rectus or adducted attitude in reference to the rearfoot. The rectus foot has a metatarsus adductus angle less than 15°. An angle larger than 15° causes the hallux valgus deformity to appear more severe than it actually is.

The normal upper limit for the hallux abductus angle is 15-20°. This angle is the abduction of the longitudinal bisection of the proximal phalanx and first metatarsal; it is also known as the first metatarsal phalangeal angle. This is the primary method for quantification of the hallux abductus, either positional or structural.

The normal upper limit for the proximal articular set angle is 7.5°. This is a measurement of the structural position of the first metatarsal head cartilage. It is used in determining whether the joint is congruent, deviated, or subluxated (see the image below).

Congruency of first metatarsophalangeal joint. Congruency of first metatarsophalangeal joint.

The upper limit of normal for the distal articular set angle is 7.5°. This angle detects structural abnormalities of the proximal phalanx base. Abnormalities may indicate the need for proximal phalanx osteotomies. The angle is determined by longitudinal bisection of the proximal phalanx of the hallux with reference to a line that connects the medial and lateral extents of the proximal phalangeal articular surface. The degree of abduction of the phalangeal bisection away from 90° determines this angle.[9]

Sesamoid positions 1-3 are normal, and the range is 1-7 (see the image below). In pathologic hallux valgus, the crista often is eroded as a result of the laterally deviated position of the sesamoids. The sesamoid position represents the degree of lateral subluxation of the sesamoid apparatus.

Tibial sesamoid position with bisection of first m Tibial sesamoid position with bisection of first metatarsal. Positions 1-3 are normal. Positions 4-7 indicate erosion of crista and laterally track-bound, nonreducible hallux valgus.

The normal range for the first metatarsal declination angle is 15-30°. This angle is determined by bisection of the first metatarsal shaft in reference to the weightbearing surface. This is a useful evaluation for selection of a procedure that includes plantarflexion of the metatarsal in the sagittal plane.

The upper limit of normal for the hallux valgus interphalangeus angle is 10°. A larger angle indicates a structural deformity of either the proximal phalanx head or the distal phalanx base, which gives the hallux an abducted appearance that is occasionally confused with a hallux valgus deformity. Inability to detect an abnormal angle may lead the surgeon to overcorrect a hallux abductus. The angle of abduction is determined on an AP view from longitudinal bisection of the proximal phalanx compared with longitudinal bisection of the distal phalanx.

In a study aimed at assessing the intraobserver and interobserver reliability of radiographic methods used to measure the hallux valgus and intermetatarsal angles and determining the most reliable method for making those measurements before and after a proximal crescentic osteotomy of the first metatarsal, Shima et al found the most reliable method to be one in which a line connected the centers of the first metatarsal head and the proximal articular surface of the first metatarsal to define the longitudinal axis of the first metatarsal.[10]

Radiologic pathology

Radiographs may be useful in evaluating the condition of the first MTP joint. Two main aspects should be evaluated.

The first aspect is the width and uniformity of the joint space (see the images below). Normally, the joint space appears uniform. An increase or irregularity is indicative of degenerative changes. Therefore, if the osteoarthritis is severe enough, a joint-destructive procedure should be entertained.[11]

Bunion deformity with minimal joint destruction. Bunion deformity with minimal joint destruction.
Bunion deformity with significant joint destructio Bunion deformity with significant joint destruction.

The joint should also be evaluated for osteophytes at the articular margins. The normal joint is free of osteophytes. Osteophytes are yet another indication of the severity of degeneration.

Radiographic bone stock assessment

Radiography is an excellent method for determining the quality and density of bone. In general, bone density should be uniform and trabeculation should be fine. The head of the metatarsal should be evaluated for cysts. In the normal metatarsal head, cysts should not be observable. Cysts indicate structural adaptation of the bone to function and load, or systemic arthritis.

Severe osteopenia or cysts may preclude the use of various forms of internal fixation or osteotomy. Note any increased density of the second metatarsal, which indicates excessive forces on the second metatarsal due to instability of the first metatarsal. Stress fractures of the second metatarsal commonly occur in this setting (see the image below).

Large intermetatarsal angle and hallux abductovalg Large intermetatarsal angle and hallux abductovalgus deformity secondary to previous injury. Note increased cortical density of second, third, and fourth metatarsals.

Other radiographic findings

The hallux valgus, the medial eminence, and the soft tissue are evaluated as follows:

  • Hallux valgus - No valgus rotation, as noted by the symmetrical concavity of the borders the medial and lateral shafts, should be evident. Asymmetry indicates the need for a procedure to the proximal phalanx to derotate the hallux
  • Medial eminence - The normal metatarsal head is free from excessive bony proliferation; bony proliferation indicates an the imbalance of the joint with excessive medial tension
  • Soft tissue - The soft tissues are evaluated for edema, bursae, calcification, or other signs of chronic inflammation
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Staging

Root et al divided the pathomechanical development of hallux valgus into four stages as follows[12] :

  • Stage 1 - Excessive pronation causes hypermobility of the first ray, causing the tibial sesamoid ligament to be stretched and the fibular sesamoid ligament to contract; lateral subluxation of the proximal phalanx occurs
  • Stage 2 - Hallux abduction progresses, with the flexor hallucis longus and flexor hallucis brevis gaining lateral mechanical advantage
  • Stage 3 - Further subluxation occurs at the first MTP joint, with formation of metatarsus primus adductus
  • Stage 4 - The first MTP joint finally dislocates
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Contributor Information and Disclosures
Author

Crista J Frank, DPM Podiatrist, Department of Orthopaedics, United States Naval Hospital, Okinawa, Japan

Crista J Frank, DPM is a member of the following medical societies: American College of Foot and Ankle Surgeons, American Podiatric Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Dan E Robinson, DPM Chief, Section of Podiatry, Dwight D Eisenhower Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Noriko Satake, MD Assistant Professor, Department of Pediatric Hematology/Oncology, University of California, Davis, School of Medicine, UC Davis Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Anthony E Johnson, MD Chairman, Department of Orthopaedic Surgery, San Antonio Military Medical Center; Research Director, US Army–Baylor University Doctor of Science Program (Orthopaedic Physician Assistant); Custodian, Military Orthopaedic Trauma Registry; Associate Professor, Department of Surgery, Baylor College of Medicine; Associate Professor, The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences

Anthony E Johnson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Healthcare Executives, American College of Sports Medicine, American Orthopaedic Association, Arthroscopy Association of North America, Association of Bone and Joint Surgeons, International Military Sports Council, San Antonio Community Action Committee, San Antonio Orthopedic Society, Society of Military Orthopaedic Surgeons, Special Operations Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Society of Military Orthopaedic Surgeons; American Academy of Orthopaedic Surgeons<br/>Received research grant from: Congressionally Directed Medical Research Program<br/>Received income in an amount equal to or greater than $250 from: Nexus Medical Consulting.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

Acknowledgements

Dale D Dalenberg, MD Orthopedic Surgeon, Leavenworth Bone & Joint Surgery Clinic, PA

Disclosure: Nothing to disclose.

Christopher E Gentchos, MD Orthopedic Surgeon, Concord Orthopaedics, PA

Christopher E Gentchos, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, and New Hampshire Medical Society

Disclosure: Nothing to disclose.

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Rheumatoid arthritis. Note greater deformity of right foot (image left) versus left foot (image right).
Rheumatoid arthritis. Note lateral deviation of hallux, cystic changes of metatarsal head, and hammertoe of lesser digits.
Line of pull of extensor hallucis longus causing metatarsal to deviate medially and hallux to deviate laterally.
Nonweightbearing foot. Note medial prominence, contracture of extensor hallucis longus, and callus on second digit.
Nonweightbearing foot with range of motion being assessed of first ray, which is currently in neutral (neither plantarflexed or dorsiflexed) position.
Lateral view of first metatarsophalangeal joint with ligaments of sesamoid complex.
Plantar muscles that contribute to deforming forces.
Anteroposterior and lateral radiographs, weightbearing views.
Medial bony enlargement is more prominent on this lateral oblique projection than on other views.
Template showing angular measurements.
Another template showing increased angular relationships.
Congruency of first metatarsophalangeal joint.
Tibial sesamoid position with bisection of first metatarsal. Positions 1-3 are normal. Positions 4-7 indicate erosion of crista and laterally track-bound, nonreducible hallux valgus.
Bunion deformity with minimal joint destruction.
Bunion deformity with significant joint destruction.
Large intermetatarsal angle and hallux abductovalgus deformity secondary to previous injury. Note increased cortical density of second, third, and fourth metatarsals.
Algorithm for choosing surgical correction of hallux abductovalgus. Click image to enlarge.
Hallux abductovalgus deformity.
Postoperative radiograph obtained after head osteotomy.
Preoperative radiograph.
Postoperative radiograph shows Keller, or resectional, arthroplasty.
Preoperative radiograph shows degenerative joint disease.
Postoperative radiograph obtained after resectional arthroplasty and total joint implant placement.
Preoperative template for implant placement.
Preoperative radiograph shows arthrodesis.
Postoperative radiograph show arthrodesis.
Preoperative radiograph shows hypermobile first ray.
Postoperative radiograph shows arthrodesis of first metatarsocuneiform.
Lateral release sequence: (1) release of conjoined adductor hallucis tendon, (2) release of fibular sesamoid ligament, (3) tenotomy of lateral head of flexor hallucis brevis, and (4) excision of fibular sesamoid.
 
 
 
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